Poor oversight of resident physicians contributed to deadly lung cancer diagnosis delay, OIG says
Poor oversight of resident physicians contributed to a deadly delay in diagnosing one patient’s lung cancer, according to the results of an investigation released Tuesday.
The Department of Veterans Affairs Office of the Inspector General launched the inquiry last year after receiving reports of postponements and deficiencies in care coordination at an Albuquerque, New Mexico, facility. In one instance, a VA urology resident requested surveillance of the abdomen and pelvis within 90 days in mid-summer 2017, but it ended up taking nearly 175 to complete.
“The supervising provider was not alerted to the results and neither the resident nor the supervising provider acted on the radiologist’s recommendation for a follow-up chest CT scan to be completed in three months,” the OIG reported Nov. 23.
Scans eventually unearthed a suspicious nodule while a radiologist-recommended follow-up PET/CT showed a lesion in the right lung, the report noted. The patient was slated for a pulmonary clinic visit in spring 2018, but a week prior to the appointment, the individual’s symptoms worsened, leading to a VA emergency department visit. After a limited review of the patient’s history, which did not include prior imaging, the patient was sent home.
Their condition worsened, leading the individual to miss the pulmonary appointment, and a fellow phoned to discuss the PET/CT results, though no biopsy was arranged. Instead, the pulmonary fellow ordered an infection workup, antibiotics, and another pulmonary appointment. This despite the patient having a history of smoking and exposure to asbestos.
“The OIG found no documented evidence of supervisory oversight of the fellow,” the report noted. “The patient continued to decline and had visits with the primary care provider. Finally, the patient sought care at two non-VA hospitals, where a biopsy was done, and a diagnosis of cancer was made six weeks after the PET/CT scan report noted the cancer.”
OIG concluded that the Raymond G. Murphy VA Medical Center had deficiencies in care coordination between pulmonary providers primary care and the ED. The latter two did not consider recently available imaging and other information when making their medical decisions. The inspector general noted that, if images were interpreted by facility radiologists or VA telerads, chest X-rays might have been compared up against previous CTs, changing the interpretation.
OIG urged the center’s director to ensure consistency between interpretations handled by staff and contracted teleradiologists. It also recommended that supervising providers establish a means to receive alerts for the results of all tests ordered by residents, among several other remedies.
You can find the full report here.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.